EMERGENCY CONTACT INFORMATION

This information will only be used if you are seriously injured or die. Please provide a contact person who can make important medical and other decisions for you if you are unable to do so for yourself. IF YOU DO NOT HAVE THIS INFORMATION, MARK "X" ON THE LINE AND GO ON TO THE NEXT QUESTION.

* Required

Student Name: *

LSU ID# *

Primary Emergency Contact

(In the United States)

First Name: * (Legal Name)

Last Name: * (Legal Name)

Relationship to you: *

Language( s ) spoken by this emergency contact: *

Gender: *

Male
Female

Street Address: *

City: *

State/Province: *

Postal Code: *

Home Telephone Number: * 000-000-0000

Cell Phone Number: * 000-000-0000

Work Telephone Number: * 000-000-0000

Fax Number: * 000-000-0000

E-mail Address: *

Emergency Contacts

(Can be outside the US)

First Name: *

Last Name: *

Relationship to you: *

Language( s ) spoken by this emergency contact: *

Gender: *

Male
Female

Street Address: *

City: *

State/Province:

Country: *

Postal Code:

Home Telephone Number: * Please type the numbers as you would dial them from the US (including country codes, area codes, etc.)

Work Telephone Number:

Cell Phone Number:

Fax Number:

E-mail Address:

RELEASE

The Office of International Student Services at La Sierra University has my permission to release information to my emergency contacts/parents, authorized representatives of my government, sponsor, and/or the authorized representatives of the United States government. In the event of an emergency involving my death or serious injury, I authorize my emergency contacts to receive medical and other necessary information so they may act on my behalf in such activities as banking, medical decisions, health insurance, billing, etc. I further authorize International Student Services to obtain and relay to my emergency contacts information about my medical condition.

By checking this box, I understand the above statements concerning the release of my information in the event of a release. *